Power-Up Friday, Real Problems, Real Solutions

The University of Iowa’s Geriatric Education Center recently sent out a summary of studies year-to-date regarding “Management of Behavioral and Psychological Symptoms of Dementia”. Here’s a brief summary of the nine studies quoted:

(1) One study could not prove that stroke incidence was increased with antipsychotics, while another said it likely was increased.

(2) Antipsychotic use has increased in recent years in nursing homes without evidence of any coherent thought process, and out-of-proportion to any increase in dependency or behavioral symptoms over the years.

(3) Several studies were so “brave” as to say that “caution” should be exercised before using antipsychotic drugs in dementia, even though their data suggest that this wording is too mild.

Here’s a challenge: The REAL problem is not that these drugs are largely ineffective and dangerous when used for behavioral distress. The REAL problem is not even that we over-medicate people with dementia.

The REAL problem is that the very notion that this distress requires any pill is a flawed paradigm.

The REAL solution is not to find better pills. The REAL solution is Real Care.

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About Dr. Al Power, ChangingAging Contributor

Al Power is a geriatrician, author, musician, and an international educator on transformational models of care for older adults, particularly those living with changing cognitive abilities. You can follow his speaking schedule at http://www.alpower.net/gallenpower_schedule.htm

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Comments

For me, the goal is to avoid situations where my doctor even suggests that I need to be taking drugs. I think that the damage from drugs (which treat symptoms and not conditions) is way worse than the symptom. In every case so far, I have found a natural way to maintain health. I just hope I can manage to the finish line.

This is clearly a very challenging situation for any model of care, and one for which there is no perfect answer. I often remind people that culture change doesn’t make life simpler — it often makes it more challenging because it raises the bar of accountability.

Having said that, I can add a few comments about how a more experiential approach to care might differ from the traditional. First of all, the fracture is a reality, and it’s not something easily immobilized, so it must be very painful. So let’s start with the medical aspects: is pain adequately controlled? How much of her “behavior” is actually pain? Culture change is more than just eliminating meds–it’s appropriate use of the right meds, and a broken hip that can’t be pinned needs something on the order of morphine for adequate control.

Second, have the surgical options been exhausted? There’s no doubt that the aortic stenosis rules out spinal anesthesia, and possibly general as well. Do the orthopedists have any other innovative approaches (like percutaneous placement of screws using pain meds and conscious sedation (ie Versed)? I don’t know the answer, but has anyone asked the question?

What are her values? How does she want to live (or not want to live)? Does anyone know her well enough to say “she would chance the surgery rather than live like this”, or “she would go on Hospice in this situation”, rather than blindly following medical algorithms?

Now beyond the medical. What is she experiencing? Do the caring 24-hour staff members truly know her as a person — her history, what gives her life meaning and connection, and does she know them (or are they just rotating staff who are caring, but don’t really know her and treat her as simply “a patient with dementia and behaviors”)?

Does she miss the flow of life? Not being able to get out of bed does not mean room-bound. She could be just as comfortable in a recliner, out in an area with other people around, even taken outside (gently) for fresh air.

Redirection doesn’t work. It’s usually better to go to her place, rather than trying to bring her to ours. Validate the emotion first and make all connections at that level. Connect through conversation, touch, music, whatever helps her to redirect her own anxieties. Facts usually don’t help in this situation.

The bottom line is that she is expressing unmet needs through her behavioral distress. You may not meet them perfectly with all your best efforts, but a drug NEVER will — it just sedates, which is a staff-centered, rather than a person-centered solution.

Just scratching the surface here with a few possibilities, because I don’t know her or the situation well. These ideas may not answer her situation correctly, but they are the type of questions “Real Care” might ask, that often don’t get asked in traditional settings.